Trends and insights review. Nerve procedures in the management of upper limb spasticity.

This article reviews the recent advances or nerve-oriented surgical procedures in the treatment of the spastic upper limb. The idea to intervene on the nerve is not recent, but new trends have developed in nerve surgery over the past few years, stimulating experiments and research. Specific surgical procedures involving the nerves have been described at different levels from proximal to distal: at the cervical spinal cord and the dorsal root entry zone (rhizotomy), at the level of the roots (contralateral C7 transfer) or in the peripheral nerve, within the motor trunk (selective neurectomy) or as its branches penetrate the muscles (hyperselective neurectomy). All of these neurosurgical procedures are only effective on spasticity but do not address the other deformities, such as contractures and motor deficit. Additional procedures may have to be planned in conjunction with nerve procedures to optimize outcomes.

[Evolution of the rate of episiotomies and obstetric anal sphincter injuries since the last recommendations of 2018]. / Évolution du taux d'épisiotomies et des lésions obstétricales du sphincter de l'anus depuis les recommandations de 2018.

OBJECTIVES: There is a progressive reduction in the rate of episiotomies since the recommendations of the French college of gynaecologists. Our objective was to study the evolution of the rate of episiotomies and Obstetric Anus Sphincter Injury (OASI) since the restriction of episiotomies in our department. METHODS: Observational monocentric retrospective study performed at the Rouen University Hospital. The inclusion criteria were monofetal pregnancies, delivery at a term greater than or equal to 37 weeks of amenorrhea of a living, viable child and by cephalic presentation. We compared two periods corresponding to before and after the 2018 recommendations. We used logistic regression modelling to identify factors associated with the risk of episiotomies and of obstetrical anal injuries, overall and in case of instrumental delivery. RESULTS: We included 3329 patients for the 1st period and 3492 for the 2nd period, and the rate of instrumental deliveries were respectively of 16.4% (n=547) and 17.9% (n=626). Multivariate analysis showed a significant decrease in the rate of episiotomies in the 2nd period (OR 0.14, CI 95% [0.12; 0.16], P<0.0001). Main factors associated with the risk of OASI were primiparity (OR 6.21, CI 95% [3.19; 12.11]) and the use of forceps (OR 4.23, CI 95% [2.17; 8.27]) overall; and instrumental delivery using forceps (OR 3.25, CI 95% [1.69; 6.22]) and delivery during the 2nd period (OR 1.98, CI 95% [1.01; 3.88]) in case of instrumental delivery. CONCLUSIONS: Our study confirms that the voluntary reduction in the episiotomy rate does not seem to be associated with an increased risk of OASI, overall and in case of instrumental delivery. However, we show an increase in the rate of OASI in case of instrumental delivery since the latest recommendations.

Osteochondritis dissecans of the finger in a young climber. A case report.

We report the case of a 17-year-old climber presenting a rare case of osteochondritis dissecans of a proximal interphalangeal finger joint. A thorough bibliographic search confirmed the rarity of this pathology. The diagnosis and treatment choice are discussed in view of the literature findings.

Nerve transfers in the forearm: potential use in spastic conditions.

PURPOSE: Deformities of the spastic upper limb result frequently from the association of spasticity, muscle contracture and muscle imbalance between strong spastic muscles and weak non-spastic muscles. This study was designed to evaluate the feasibility of combining selective neurectomy of the usual spastic and strong muscles together with transfer of their motor nerves to the usual weak muscles, to improve wrist and fingers motion while decreasing spasticity. METHODS: Twenty upper limbs from fresh frozen human cadavers were dissected. All motor branches of the radial and median nerve for the forearm muscles were identified. We attempted all possible end-to-end nerve transfers between the usually strong "donor" motor branches, namely FCR and PT, and the usually weak "recipient" motor branches (ERCL, ECRB, PIN, AIN). RESULTS:  The PT had two nerve branches in 80%, thus allowing selective neurectomy. The proximal PT branch could be anastomosed end-to-end in 45% (AIN) to 85% (ECRL) of cases with the potential recipient branches. The distal PT branch could be anastomosed end to end to all potential recipient nerves. The FCR had a single branch in all cases. End-to-end anastomosis was possible in 90% for the ECRL and in 100% for all other recipient branches, but sacrificed all FCR innervation, ruling out hyperselective neurectomy. CONCLUSION:  Selective neurectomies can be associated with distal nerve transfers at the forearm level in selected cases. The motor nerve to the PT is the best donor for nerve transfer combined with selective neurectomy, transferred to the ECRL, ECRB, PIN or AIN.

Fractional Lengthening of the Forearm Flexor Muscles: Anatomic Study.

PURPOSE: Forearm muscles can undergo contracture for a number of reasons, including spasticity. This deformity is amenable to surgical treatment in select cases. Among the different techniques available, fractional lengthening of the forearm flexor muscles involves multiple tenotomies at the musculotendinous junction. We studied the anatomy of the musculotendinous junction of all forearm flexor muscles to analyze the topography and extent of muscle-tendon overlapping for each muscle and to determine the area where fractional lengthening can be performed safely. METHODS: Dissections were performed on 20 fresh cadaveric upper limbs. For each muscle, we defined and measured the total overlapping zone, "corrected" overlapping zone, and useful zone (UZ), along with 3-dimensional mapping of the location of each tendon with respect to the muscles' fibers. RESULTS: With regard to the wrist flexors, the average UZ was very short for the flexor carpi radialis (3.5 cm) and very long for the flexor carpi ulnaris (12.2 cm). With regard to the finger flexors, the UZ of the superficialis tendons varied greatly (2.7-5.9 cm), whereas it was relatively constant for the profundi (7.6 cm) and flexor pollicis longus (6.5 cm). CONCLUSIONS: Fractional lengthening is dependent on the anatomy of the musculotendinous junction of each individual muscle. For muscles with a relatively short and variable UZ (flexor carpi radialis, flexor digitorum superficialis [FDS] II, and FDS IV), the feasibility of the procedure must be carefully evaluated intraoperatively. For FDS V, which constantly displays a very short UZ, with a thin and fragile tendon, the procedure may be risky and unreliable. CLINICAL RELEVANCE: When considering fractional lengthening of the forearm muscles, differences between the tendons should be considered, and surgeons should be prepared for alternative approaches, especially for FDS V.

Nerve transfer in the spastic upper limb: anatomical feasibility study.

PURPOSE: Nerve transfers represent an innovative tool in the surgical treatment of upper limb paralysis. Well-documented for brachial plexus sequalae and under evaluation for tetraplegic patients, they have not yet been described for spastic upper limbs. The typical spastic deformity involves active and spastic flexor, adductor and pronator muscles, associated with paralysed extensor and supinator muscles. Experience with selective neurectomy has shown an effective decrease in spasticity together with preservation of muscle strength. We conceptualized a combination of neurectomy and nerve transfer, by performing a partial nerve transfer from a spastic elbow flexor muscle to a paralyzed wrist extensor muscle, hypothesizing that this would reduce the spasticity of the former and simultaneously activate the latter. METHODS: Ten cadaveric dissections were performed in order to establish the anatomic feasibility of transferring a motor branch of the brachioradialis (BR) onto the branch of the extensor carpi radialis longus (ECRL) or brevis (ECRB). We measured the emergence, length, muscle entry point and diameter of each branch, and attempted the transfer. RESULTS: We found 1-4 motor nerve for the BR muscle and 1-2 for the ECRL muscle. In all cases, the nerve transfer was achievable, allowing a satisfactory coaptation. The ECRB branch emerged too distally to be anastomosed to one of the BR branches. CONCLUSION: This study shows that nerve transfers from the BR to the ECRL are anatomically feasible. It may open the way to an additional therapeutic approach for spastic upper limbs.

Hyperselective neurectomy for the treatment of upper limb spasticity in adults and children: a prospective study.

Hyperselective neurectomy (HSN) procedures in the spastic upper limb aim to reduce tone by excising some branches of the involved peripheral motor nerves, at the point of entry of each motor ramus into the target muscle. In this prospective study, 42 patients with upper limb spasticity were treated by HSN for the muscles of elbow flexion, forearm pronation and wrist flexion and evaluated for their short-term results (average 6 months) and long-term outcomes (average 31 months). Results at both time points showed an effective reduction of the spastic tone, with no decrease of muscle strength in the operated spastic muscles. Comparison of results between the two time points showed durability of the improvement, which remained statistically significant despite a slight relapse in spasticity. The results of HSN compare favourably with the other techniques of partial neurectomy; however, the technique requires a detailed knowledge of upper limb motor anatomy.Level of evidence: II.

Anatomical study of the deep branch of the ulnar nerve and application to selective neurectomy in the treatment of spasticity of the first web space.

PURPOSE: Spasticity of the first web space is common in upper limb spasticity. Selective neurectomy is one of the treatments that can reduce spasticity. The purpose of this study was to describe the variations of the deep motor branch of the ulnar nerve for the adductor pollicis (AP) and the first dorsal interosseous muscle (DIO) to assess the feasibility of selective neurectomy and suggest an ideal surgical approach. METHODS: The deep branch of the ulnar nerve (DBUN) was dissected in 21 hands. Measurements included the distance between the point of passage of the DBUN between the two heads of the adductor and three anatomical landmarks: the bi-styloid line, the flexor carpi radialis and the pisiform bone, and the number and mode of divisions of each branch. RESULTS: The point of passage of the DBUN between the two heads of the adductor is very constant respective to the landmarks. The DBUN gives off 1-3 branches each for the oblique head of the AP, the transverse head, and the first DIO. Muscles receive more than one branch in 95% cases for the oblique head and 62% of cases for the transverse head, and 100% for the DIO. CONCLUSIONS: This anatomical study suggests that selective neurectomy is feasible for the AP and first DIO muscles in most cases. An ideal approach for selective neurectomy of these muscles should start from the point of passage of the DBUN between the two heads of the AP. This point is easily identified with the help of the described landmarks.

Selective Neurectomy for the Spastic Upper Extremity.

Surgery is one element of the rehabilitative care of the spastic upper limb. Different surgical techniques have been advocated to address each of the common deformities and underlying causes, including muscle spasticity, joint contracture, and paralysis. Partial neurectomy of motor nerves has been shown to reduce spasticity in the target muscles. It is effective only for the spastic component of the deformity, which underscores the importance of a preliminary thorough clinical examination. Hyperselective neurectomy, which involves performing a partial division of each motor ramus at its entry point into the target muscle, results in improved selectivity, reliable partial muscle denervation, and durable results.

Complications of Wrist Arthroscopy: A Multicenter Study Based on 10,107 Arthroscopies.

Background Wrist arthroscopy is now a routine procedure, regarded as safe. Complications are reported in the literature as being rare and mostly minor. Purpose The two goals of this study were to evaluate the incidence and nature of complications based on a very large multicenter retrospective study, and to investigate about a potential learning curve. Methods The authors sent a detailed questionnaire to all members of the European Wrist Arthroscopy Society (EWAS), inquiring about the number and types of complications encountered during their practice of wrist arthroscopy, and about their experience with the technique. Results A total of 36 series comprising 10,107 wrist arthroscopies were included in the study. There were 605 complications (5.98% of the cases), of which 5.07% were listed as serious and 0.91% as minor. The most frequent ones were failure to achieve the procedure (1.16%), and nerve lesions (1.17%). Cartilage lesions and complex regional pain syndrome each occurred in 0.50% cases. Other complications (wrist stiffness, loose bodies, hematomas, tendon lacerations) were less frequent. Breaking down of the data according to each surgeon's experience of the technique showed a significant relationship with the rate of complications, the threshold for a lower complication rate being approximately 25 arthroscopies a year and/or greater than 5 years of experience. Conclusion Although the global incidence of complications was in keeping with the literature, the incidence of serious complications was much higher than previously reported. There is a significant learning curve with the technique of wrist arthroscopy, both in terms of volume and experience.

Anatomical study of the motor branches of the median nerve to the forearm and guidelines for selective neurectomy.

PURPOSE: The median nerve is responsible for the motor innervation of most of the muscles usually involved in upper limb spasticity. Selective neurectomy is one of the treatments utilized to reduce spasticity. The purpose of this study was to describe the variations of the motor branches of the median nerve in the forearm and draw recommendations for an appropriate planning of selective neurectomy. MATERIALS AND METHODS: The median nerve was dissected in the forearm of 20 fresh cadaver upper limbs. Measurements included number, origin, division, and entry point of each motor branch into the muscles. RESULTS: One branch for the pronator teres was the most common pattern. In 9/20 cases, it arose as a common trunk with other branches. A single trunk innervated the flexor carpi radialis with a common origin with other branches in 17/20 cases. Two, three or four branches innervated the flexor digitorum superficialis, the first one frequently through a common trunk with other branches. They were very difficult to identify unless insertions of pronator teres and flexor digitorum superficialis were detached. The flexor digitorum profundus received one to five branches and flexor pollicis longus one to two branches from the anterior interosseous nerve. CONCLUSIONS: There is no regular pattern of the motor branches of the median nerve in the forearm. Our findings differ in many points from the classical literature. Because of the frequency of common trunks for different muscles, we recommend the use of peroperative electrical stimulation. Selective neurotomy of flexor digitorum superficialis is technically difficult, because the entry point of some of their terminal branches occurs just below the arch and deep to the muscle belly.

Combined Treatment of Wrist and Trapeziometacarpal Joint Arthritis.

Background Combined thumb basal and wrist joint arthritis (excluding scaphotrapeziotrapezoid arthritis) is rare considering the frequency of arthritis of either joint alone. Combined surgical treatment has never been described in the literature. Furthermore, the scaphoidectomy common to all interventions for Watson stage 2 or 3 wrist arthritis theoretically makes it impossible to perform a trapeziectomy for thumb basal joint arthritis. Question/Purpose The aim of this study was to present and analyze the results of two types of surgical treatment when both wrist and thumb arthritis was present. Materials and Methods Our retrospective series included 11 patients suffering from Eaton Stage III thumb basal joint arthritis and scapholunate advanced collapse (SLAC) II and III-type wrist arthritis. Five patients (group A) underwent trapeziectomy and palliative surgery for their wrist with conservation of the distal pole of the scaphoid (one proximal row carpectomy [PRC] and four four-corner fusions), and six (group B) patients had a trapeziometacarpal arthroplasty either with PRC (two cases) or four-corner arthrodesis (four cases) including total scaphoidectomy. Results The mean follow-up was 57 months. The overall visual analog scale (VAS) score for pain was 1.5 at rest, with no difference between the trapeziectomy and arthroplasty groups. The average Kapandji score was 9.3 (9 in group A and 9.5 in group B). The flexion/extension range of motion for the wrist was 64° following four-corner arthrodesis and 75° following PRC. Only one case of algodystrophy was observed. The radiological analysis revealed no complications. Discussion This study shows that thumb basal joint arthritis and SLAC type wrist arthritis may be treated by combined treatment during the same intervention without any complications. The results of palliative surgery for the wrist, either with trapeziectomy or with a trapeziometacarpal arthroplasty, are comparable. With a trapeziectomy, the distal pole of the scaphoid must be fused to the capitate to help stabilize the thumb column. Level of Evidence Level IV.

Universal Dorsal Approach of the Wrist.

The ideal dorsal wrist approach has to provide the best exposure while preserving sensitive dorsal nerve branches, dorsal veins, and skin integrity. Longitudinal incision is mostly used in the wrist surgery. Few anatomic or clinical studies have described transverse dorsal approach following Langer's lines. We present a universal transversal skin incision, the design of which meets the requirements of a dorsal wrist approach. It is adjustable with the radial and ulnar extension and respects Langer's lines, nerves, and veins. We conducted both an anatomic, clinical, and a retrospective study. For the anatomic part, we performed a cadaveric study on the wrist. For the clinical part of the study, we analyzed clinical results for 10 consecutive patients who underwent a universal dorsal wrist approach for various surgical procedures by the same surgeon. For the last part, we reviewed the patients operated during the past 5 years with this approach for different procedures in the wrist.

Outcome measures for hand function naturally reveal three latent domains in older adults: strength, coordinated upper extremity function, and sensorimotor processing.

Understanding the mapping between individual outcome measures and the latent functional domains of interest is critical to a quantitative evaluation and rehabilitation of hand function. We examined whether and how the associations among six hand-specific outcome measures reveal latent functional domains in elderly individuals. We asked 66 healthy older adult participants (38F, 28M, 66.1 ± 11.6 years, range: 45-88 years) and 33 older adults (65.8 ± 9.7 years, 44-81 years, 51 hands) diagnosed with osteoarthritis (OA) of the carpometacarpal (CMC) joint, to complete six functional assessments: hand strength (Grip, Key and Precision Pinch), Box and Block, Nine Hole Pegboard, and Strength-Dexterity tests. The first three principal components suffice to explain 86% of variance among the six outcome measures in healthy older adults, and 84% of variance in older adults with CMC OA. The composition of these dominant associations revealed three distinct latent functional domains: strength, coordinated upper extremity function, and sensorimotor processing. Furthermore, in participants with thumb CMC OA we found a blurring of the associations between the latent functional domains of strength and coordinated upper extremity function. This motivates future work to understand how the physiological effects of thumb CMC OA lead upper extremity coordination to become strongly associated with strength, while dynamic sensorimotor ability remains an independent functional domain. Thus, when assessing the level of hand function in our growing older adult populations, it is particularly important to acknowledge its multidimensional nature-and explicitly consider how each outcome measure maps to these three latent and fundamental domains of function. Moreover, this ability to distinguish among latent functional domains may facilitate the design of treatment modalities to target the rehabilitation of each of them.

Motor branches of the ulnar nerve to the forearm: an anatomical study and guidelines for selective neurectomy.

PURPOSE: Precise knowledge of motor nerve branches is critical to plan selective neurectomies for the treatment of spastic limbs. Our objective is to describe the muscular branching pattern of the ulnar nerve in the forearm and suggest an ideal surgical approach for selective neurectomy of the flexor carpi ulnaris. METHODS: The ulnar nerve was dissected under loop magnification in 20 upper limbs of fresh frozen cadavers and its branches to the flexor carpi ulnaris muscle (FCU) and to the flexor digitorum profundus muscle (FDP) were quantified. We measured their diameter, length and distance between their origin and the medial epicondyle. The point where the ulnar artery joined the nerve was observed. The position in which the ulnar nerve gave off each branch was noted (ulnar, posterior or radial) and the Martin-Gruber connection, when present, had its origin observed and its diameter measured. RESULTS: The ulnar nerve gave off two to five muscular branches, among which, one to four to the FCU and one or two to the FDP. In all cases, the first branch was to the FCU. It arose on average 1.4 cm distal to the epicondyle, but in four specimens it arose above or at the level of the medial epicondyle (2.0 cm above in one case, 1.5 cm above in two cases, and at the level of the medial epicondyle in one). The first branch to the FDP arose on average 5.0 cm distal to the medial epicondyle. All the branches to FDP but one arose from the radial aspect of the ulnar nerve. A Martin-Gruber connection was present in nine cases. All motor branches arose in the proximal half of the forearm and the ulnar nerve did not give off branches distal to the point where it was joined by the ulnar artery. CONCLUSIONS: The number of motor branches of the ulnar nerve to the FCU varies from 2 to 4. An ideal approach for selective neurectomy of the FCU should start 4 cm above the medial epicondyle, and extend distally to 50% of the length of the forearm or just to the point where the ulnar artery joins the nerve.

Treatment of a fractured juxta-articular enchondroma of the middle phalanx with a Suzuki external fixator: a case report.

We report the case of a 47-year-old man who presented with a pathologic fracture of the middle phalanx of the fourth finger. The treatment of this juxta-articular lesion close to the proximal interphalangeal joint was performed in 2 stages. First, a biopsy was carried out combined with fixation of the fracture by a Suzuki dynamic external fixator. After 6 weeks, a curettage of the confirmed enchondroma was performed with iliac crest grafting, leaving the external fixator for another 4 weeks. With a follow-up of 48 months, a satisfying functional result has been obtained with a remarkable remodeling of the painless proximal interphalangeal joint.

Anatomical study of the musculocutaneous nerve branching pattern: application for selective neurectomy in the treatment of elbow flexors spasticity.

PURPOSE: Spastic flexion deformity of the elbow is mainly mediated by the biceps brachii and the brachialis muscles, innervated by the musculocutaneous nerve. Selective neurectomy of the musculocutaneous nerve showed promising results to relieve excessive spasticity in the long term but lacks of a consensual surgical strategy. The aim of the study was to describe the distal branching pattern of the motor branches of the musculocutaneous nerve in an attempt to develop guidelines for surgery. METHODS: Sixteen arms of fresh cadaver specimen were dissected. We recorded the site of each primary and terminal motor branch as a percentage of the distance from the coracoid process to the lateral epicondyle. RESULTS: The biceps muscle was innervated by one to five primary motor branches. The first branch emerged from the nerve at an average of 37.1% of the arm length, and the most distal terminal branch at 55.7%. The brachialis muscle received one to three primary branches. The first branch exited the nerve at an average of 51.7% of the arm length and the last terminal branch at 69.3%. The average number of terminal branches dedicated to the biceps and the brachialis muscles were, respectively, 7.9 and 6.5. CONCLUSIONS: According to our findings, we recommend to dissect the musculocutaneous nerve between 18 and 75% of the distance between the coracoid process and the lateral epicondyle to identify the motor terminal branches to the biceps brachii and the brachialis muscle, sparing sensory branches.